Liberation From Mechanical Ventilation Before Decannulation From Venovenous Extracorporeal Life Support in Severe COVID-19 Acute Respiratory Distress Syndrome.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with the significant use of venovenous extracorporeal membrane oxygenation (VVECMO) globally. Identifying strategies to optimize care is essential to improving patient important outcomes. By liberation from mechanical ventilation (MV) before VVECMO to provide awake-ECMO, complications related to MV could be minimized, leading to improved outcomes. Between March 2020 and October 2021, we conducted a prospective observational study at the Kuwait Extracorporeal Life Support Program, of patients admitted for COVID-19 acute respiratory distress syndrome (ARDS), with recording baseline characteristics, respiratory support, and ECMO parameters. Of the 207 patients who underwent VVECMO for COVID-19 ARDS during this period, only 5 patients were successfully liberated from MV before decannulation to provide awake-ECMO. Four were female with a median age of 38. Before VVECMO, all patients received corticosteroids and lung-protective ventilation with four receiving prone positioning. The median duration of MV use was 4 days, whereas the median duration of VVECMO use was 12 days, with early mobility, and all survived until hospital discharge. The safety and feasibility of liberation from MV before ECMO decannulation to provide awake-ECMO were demonstrated, but further studies are warranted to identify factors associated with this success.

Coma secondary to cerebral fat embolism syndrome due to sickle cell disease fully recovering following red cell exchange transfusion.

A 51-year-old woman known for sickle cell disease presented with 2 weeks of headache and bilateral lower limb pain. During admission, she suffered from multiple generalised tonic-clonic seizures but had an unremarkable CT of the brain. Incidentally, she had worsening baseline renal function. She was admitted to the intensive care unit with an acute confusional state. A bedside electroencephalogram showed triphasic waves and diffuse slow activity suggestive of encephalopathy with no epileptiform discharges. She remained obtunded despite appropriate medical therapy of hydration, antiepileptic and pain control. Lumbar puncture failed to identify an infectious cause. An urgent MRI of the brain was done and revealed features compatible with fat embolism syndrome (FES). Her haemoglobin S was 84.2%. Urgent red cell exchange transfusion was done, and within 3 days she fully regained her orientation and motor function. This represents the first case of such profound obtundation due to FES with a complete response to exchange transfusion.